In thesis

Pettersson, Ulrica

Swedish National Defence College, Department of Military Studies, Command & Control Studies Division.

2013 (English)Doctoral thesis, comprehensive summary (Other academic)

Abstract [en]

It is generally maintained that learning should be a part of the daily routines of many organizations; this is often referred to as lesson learned processes. The purpose of organizational learning is to foster improvements that seek to both reduce incidents and accidents and reduce their consequences when they nevertheless happen. Safety work is widespread among many organizations, e.g. aviation, hospitals, process industry, fire departments and several armed forces. A considerable part of safety work involves accident prevention, and aims to investigate why and how previous accidents and incidents happened, in order to learn how to avoid them, or minimize losses when they do occur. The collection of information after incidents represents one of the first steps in a lessons learned process, and the result is crucial for further work. Unfortunately, incident reports often tend to be unfocused (they represent a very wide area of issues) and, for that reason, cannot be clustered. They also frequently lack by analysts required information. The overall research objective in this thesis was to develop a report structure that enables the individuals who participated in or observed an incident to provide more information that is relevant about that incident. The first research question seeks to identify whether the Swedish Armed Forces face the kinds of problems that have been identified in earlier research on attempts to learn from accidents and incidents. The second and third research questions aim to ascertain whether the scope and quality of collected information in incident reports can be improved and if the number of incident reports can be increased. The results agree with earlier research and show that many of the problems that are common in other organizations (e.g. aviation, hospitals and the process industry) can also be observed and are a reality within the SwAF. In addition, the results showed that both scope and quality of collected information can be influenced. Group reporting using a consensus process neither had an appreciable effect on the quality of collected information, nor on the quantity of the reports. On the other hand, the new reporting form, which was based on interview and questionnaire methodology, and to some extent witness psychology, significantly improved the quality of the information collected after incidents. The new form proved to be superior, regardless of the character and context of the incidents. The information collected was also in accordance with what had actually happened and, finally, the form proved to be useful when various military “real world” incidents were reported. Finally, the results also provide new insights into the problems and possibilities associated with acquiring useful incident reports. The problem seems not only to be that people may be unwilling to report incidents that they have participated in or witnessed; it is also that they may be unable to do so. Consequently, it may not be sufficient to change the culture of the organization into a learning culture to receive by analysts required information. It is also necessary to help people report what they actually know by means of an improved report structure.